PATIENT AUTONOMY

AND INFORMED
CONSENT
by:
Prachi (BTB17/114)
Sneha Guha Thakurta (BTB/17/126)
Parneet Kaur (BTB/17/144)
Shreeya Sharma (BTB/17/156)
 WHAT IS INFORMED
CONSENT
o “Every human being of adult years and sound mind has a right to determine what shall be done

with his own body.”

o “Informed consent is rooted in the fundamental recognition—reflected in the legal presumption

of competency—that adults are entitled to accept or reject health care interventions on the

basis of their own personal values and in furtherance of their own personal goals.”

o But what of circumstances where patients are deemed incompetent through judicial

proceedings, and where someone else is designated to make decisions on behalf of a mentally

incompetent individual?
 CASE STUDY
• A middle aged man was involuntarily committed to a state psychiatric hospital because he was considered dangerous
to others due to severe paranoid thinking.

• His violent behavior was controlled only by injectable medications, which were initially administered against his will. He
had been declared mentally incompetent, and the decisions to approve the use of psychotropic medications were
made by his adult son who had been awarded guardianship and who held medical power of attorney.

• While the medications suppressed the patient’s violent agitation, they made little impact on his paranoid symptoms.
His chances of being able to return to his home community appeared remote.

• However, a new drug was introduced into the hospital formulary which, if used with this patient, offered the strong
possibility that he could return home.
 CASE STUDY
• The drug, however, was only available in a pill form, and the patient’s paranoia included fears that others would try to
poison him. The suggestion was made to grind up the pill and surreptitiously administer the drug by mixing it in
pudding.

• Hospital staff checked with the patient’s son and obtained informed consent from him. The “personal values and
personal goals” of the son and other family members were seen to substitute for those of the mentally incompetent
patient—and these goals included the desire for the patient to live outside of an institution and close to loved ones in
the community.

• This was the explicitly stated rationale for the son’s agreeing to the proposal to hide the medication in food. However,
staff were uncomfortable about deceiving the patient, despite having obtained informed consent from the patient’s
guardian.
 DISCUSSION
Question one
To what degree should family members or legal guardians have full capacity to make
decisions or give consent on behalf of those under their care? Explain.

1. In cases where the patient has been declared mentally incompetent the medical
power of attorney should be given to the patient's legal guardians.
2. Such decisions should also be backed by the medical board under whose care the
patient is being treated.
3. In cases where the person is of a medically sound mind , informed consent should
be of utmost importance and should be given more weightage over the decisions
taken by his legal guardians.
 DISCUSSION
Question two
Do you think severely mentally ill people retain any rights “to determine what shall
be done with [their] own [bodies]?” Why or why not?

THE MENTAL HEALTHCARE ACT-2017 of India

Any patient suffering from severe mental illness holds right to:
• protection from any inhuman, experimental or cruel treatment to them.
• live in safe and hygienic environment.
• to get adequate sanitary conditions, particularly for women.
• proper clothing.
• A legal caregiver to make them aware of their rights and/or to make sure
that the patient's rights are implemented in a proper manner when
required.
 DISCUSSION
Question three
Since psychiatric patients have the right to treatment, does the strategy to surreptitiously
administer medications serve this goal? Do you think this is ethically justifiable? Why or
why not?

“You win a battle but lose the war, if the goal is to help the person get better.
There are many ways to heal”
(Ahern & Tosh, 2005 - Presenting case against cover medication and surreptitious prescribing)

1. Key ethical principles relating to the use of concealed medication are

autonomy, justice, beneficence and respect for the patient.
2. Undermines the trust between a patient and a physician.
3. The issue of validity also governs the fact that mentally ill persons are
not treated justly because they are depraved of due fairness and
informed consent.
 DISCUSSION
Question four
Do you think it is ever ethically permissible to deceive clients? Under what
circumstances? Why or why not?

The use of coercion can be justified only if the principles of beneficence (acting in
the patient’s best interest), nonmaleficence, or justice are in strong contradiction
to the patient’s expressed will and if convincing observations indicate that the
patient’s autonomy is severely undermined.

If account is taken of patients’ own preferences, mental healthcare would

become more patient-oriented, patient compliance and safety would be
enhanced—possibly increasing not only the quality of treatment, but also
patients’ satisfaction.
 CONCLUSION
Covert medication and ‘surreptitious’ prescribing has a number of potential
advantages as well as disadvantages in treating patients suffering from severe mental
illness. The use of covert administration or deception will depend upon a number of
variables. Ethical as well as legal issues are inherent in the practice of covert
medication with a potential scope for misuse and abuse. Issues related to informed
consent and capacity, competency, dignity, autonomy and best interests of the
patients need to be looked into and safeguarded.

Consideration should be given to whether the patient is competent, detained under

the MHA or informal; and the basis upon which the use of covert administration is
proposed. Staff should be given guidance as to the criteria that should be considered
when reaching a decision on whether covert medication could be justified; a policy
and a set of guidelines can assist in directing the staff through their decisions, and
avoid overuse and abuse related to its practice.
 by:
Prachi (BTB17/114)
Sneha Guha Thakurta (BTB/17/126)
Parneet Kaur (BTB/17/144)
Shreeya Sharma (BTB/17/156)